How Can Speech and Language Therapists be Supported to Make Decisions Regarding Communication Therapy for People With Dementia? A Realist Theory-Development Study.

introductionAs of 2021, there were 57 million people with dementia worldwide, and there are 885,000 people with dementia in the UK. Communication difficulties occur in all forms of dementia. Increasing difficulty communicating thoughts and needs affects social interaction and personal relationships, with implications for individuals' and their relatives' quality of life. Speech and language therapists are trained to provide communication support to people experiencing communication difficulties. However, whether people with dementia are offered communication support from speech and language therapy services varies significantly across the UK. This study aimed to explain how speech and language therapists currently make clinical decisions about offering communication support, and to explain how further guidance such as a decision-aid for clinicians may help people with dementia to receive more equitable care.

methodsThis study used realist methods to develop a programme theory relating to speech and language therapist decision-making for dementia communication interventions, in order to inform future work to develop a decision-aid for non-dementia specialist speech and language therapists. Theories were produced and refined through an iterative process including literature review, stakeholder engagement and focus groups with speech and language therapists to help explain how speech and language therapists make decisions and how a decision-aid could support this process. Data was analysed through a top-down approach using an analytic appraisal journal, and a bottom-up approach using deductive and inductive coding.

resultsEighteen speech and language therapists participated in four focus groups. Eight theory statements were identified relating to how speech and language therapists currently make decisions about how, when and what type of communication therapy to offer people with dementia. Speech and language therapists make decisions about provision of communication therapy based on factors including staffing levels, prioritisation criteria, number of referrals received, personal beliefs, confidence, self-perceived skills, and team culture. Eight theories relating to how a proposed decision-aid might function were identified: provide therapy examples, peer support, service model examples, tailor for underserved groups, highlight the need for ongoing support, empower junior clinicians, and promote awareness of communication in dementia.

conclusionThis study explored how and why speech and language therapists make particular decisions when working with people with dementia experiencing communication difficulties, identifying possible mechanisms through which a decision-aid could assist this process. A decision-aid could address barriers to decision-making for communication support in dementia through enhancing speech and language therapists' knowledge, skills and confidence, while promoting equitable and sustained care. WHAT THIS PAPER ADDS: What is already known on this subject Progressive communication difficulties experienced as part of dementia can affect social interaction, personal relationships and quality of life of the person with dementia and their relatives. Speech and language therapists are well-placed to provide communication support, but provision of this in dementia varies widely across the UK. It is unclear how speech and language therapists currently make decisions about offering communication support in dementia. What this study adds to the existing knowledge This study uses realist methods to better understand the current decision-making processes of speech and language therapists relating to communication support in dementia. It uses literature review, stakeholder engagement and focus groups with clinicians to develop theories to help explain how decisions are currently made, and to propose mechanisms through which a decision-aid may help speech and language therapists to make informed decisions. What are the clinical implications of this study? The findings suggest that speech and language therapists face significant challenges in delivering communication therapy to people with dementia due to systemic under-resourcing, limited awareness of their role, and competing clinical priorities. The proposed decision-aid could address some of these barriers by enhancing speech and language therapists' knowledge, skills and confidence, while promoting equitable and sustained care. If effectively implemented, it has the potential to expand access to communication support, foster professional growth, and drive a broader recognition of communication as a vital element of dementia care.